The Joint Commission just released its 2009 National Patient Safety Goals, and – no surprise – they focus on infection prevention. While this seems natural today, it wasn’t always so. In fact, the conflation of infection control and patient safety is one of the most surprising twists of the patient safety revolution.

The inclusion – make that dominance – of infection prevention in the safety field was anything but preordained. The IOM Report on medical errors, which sparked the modern patient safety movement, mentions the word “infections” 8 times and the word “medications” 234 times. In other words, the Founding Fathers of patient safety didn’t appear to have preventing infections in mind when they articulated the scope of the endeavor.

So how did it come to pass that infection prevention became one of, if not the, central focus of the patient safety enterprise? The first step was recognition of the importance of measurement. Without measurable rates of adverse events, there could be no public reporting, no research demonstrating improvements, no pay for performance (or, more au currant, “no pay for errors” – note that more than half of the “no pay” entities on CMS’s present and proposed list are infections), and ultimately no one who could be held accountable for progress in safety.

But the desire for measures exposed a huge problem: uncovering most medical errors depends on self-reports by providers. (Parenthetically, this leads to an amusing situation at many hospital safety meetings I attend. A senior leader projects a graph of the hospital’s incident report trends. If the trend is upwards, the speaker inevitably coos, “This is great – we have created a ‘reporting culture!’” When the trend line slopes downward, guess what? “This is great, fewer errors!”). This measurement gap encompasses medication errors, falls, decubitus ulcers – pretty much every safety hazard in hospitals.

In fact, this problem was the reason that quality trumped safety in the first public reports of hospital performance. It is why the measures on CMS’s hospitalcompare website are of quality (aspirin and beta blockers for MI, ACE inhibitors for CHF) rather than safety – virtually no measure of safety can be tracked using easily accessible administrative data.

With one exception. Thanks to the infection control field’s long history (supported by a federal agency [the CDC] and state health departments), some healthcare-associated infections can be reliably measured. The poster child is catheter-associated bloodstream infections, and it is no surprise that it became one of the first publicly reported infections, one of the first adverse events on the “no pay for errors” list, and one of the first entities shown to be largely preventable with evidence-based interventions.

In fact, this measurability phenomenon led to the key political maneuver of the infection prevention field:

Branding a healthcare-associated infection a “preventable adverse event” meant that failure to adhere to the practices that could decrease the rates of these events could be deemed “medical errors.” Ergo, the failure by a healthcare provider to clean his or her hands wasn’t simply an annoyance to infection control professionals… it was A MEDICAL ERROR!

Just think about it: with this simple change in paradigm, the pressure to increase hand washing rates became all-pervasive, resulting in alcohol goop dispensers everywhere, vigorous PR campaigns, efforts to get providers to remind their colleagues to wash hands (or even to get patients to do the reminding), stealthy hand washing audits by infection control spies hiding in dark corners of ICUs (and, in a few gutsy hospitals, behind video monitors), and more. The payoff has been a doubling or trebling of hand washing rates in many hospitals – still not high enough, but well above the shameful rates of the past.

The next transformative moment for the infection prevention field came from another change in mental model. Up until about five years ago, the name of the game was to “manage to benchmark” – to be sure that your infection rates were in line with national norms. But, with the publication of studies (such as this) demonstrating that it was possible to bring the rates of certain infections to zero came another key shift: a goal of zero infections. And if the goal was zero, not benchmark, that meant that serious healthcare-related infections could be branded as sentinel events, mandating a root cause analysis of each one.

Suddenly, senior hospital leaders, who in the past only became involved in the infection control enterprise if there was a major outbreak, were now scrutinizing infection rates like they did their P&L statements, were participating in RCAs following cases of ventilator-associated pneumonias, and were wagging their fingers at their infection control practitioners (“Oh, really, we already have an infection control department?”) to make things right.

In a 2002 article in our Quality Grand Rounds series in the Annals of Internal Medicine, we asked my old UCSF colleague Julie Gerberding (now CDC Director) to discuss what the field of patient safety could learn from the much older field of infection control and prevention. Six years later, her words still ring true:

Precise and valid definitions of infection-related adverse events, standardized methods for detecting and reporting events, confidentiality protections, appropriate rate adjustments for institutional and case-mix differences, and evidence-based intervention programs come to mind. Perhaps most important, reliance on skilled professionals to promote ongoing improvements in care has contributed to the 30-year track record of success in infection prevention and control.

Analogously, in approaching patient safety, standard definitions should be used as much as possible when discussing adverse events and preventability. Health care organizations should be encouraged to pool data on adverse events in a central repository to permit benchmarking, and such data should be appropriately adjusted and reported. Finally, institutions should consider hiring dedicated, trained patient safety officers (comparable to infection control practitioners)…

I had the great pleasure of giving the keynote speech last week to 4000 members of the Association for Professionals in Infection Control (which is in the process of re-branding its members as “Infection Preventionists – geez, if I had only trademarked the “ist” ending when I cooked up the word “hospitalist”…). After making some of the above points to the large assemblage, I showed a picture of a group of happy Infection Preventionists and then asked why – in what should be halcyon days for the field – many aspects of their jobs are so painful. In my next post, I’ll reflect on this question, and discuss what the field of infection prevention can now learn from the broader patient safety enterprise.

2 Responses to “How Infection Prevention Came to Dominate the Patient Safety Movement”

The institution will be the “beneficiary” of the financial losses associated with the hospital derived infections identified by Medicare.
In community hospitals relationships between their administrators and the medical staffs are often contentious the measures to reduce infections (and protect revenue) even if driven by medical staff leadership will need to be implemented by paramedical personnel working for the administration.
Measures to educate (penalize) physicians and others violating infection control measures will further exacerbate these troubled relationships.
Hospital derived infections are often physician errors and to align incentives and protect patients it may be worth considering that the physicians be responsible also financially for their patients’ infections this may be draconian but necessary

In our historical recollection of infection related to patient safety, let’s not forget the role of the 1991 Harvard Medical Practice Study II, “The Nature of Adverse Events in Hospitalized Patients”. In this NEJM study, Dr. Leape and his colleagues identified that drug events were the most common type of adverse event (19%) followed by wound infections (14%).

All too often, an infection in a surgical M&M was simply cited as “a known complication” only to be promptly dismissed when breaks in technique could not be identified.

The HMPS II helped us think of infection from a different perspective. How prescient was the conclusion seventeen years ago: “Although the prevention of many adverse events must await improvements in medical knowledge, the high proportion that are due to management errors suggests that many others are potentially preventable now. Reducing the incidence of these events will require identifying their causes and developing methods to prevent errors or reduce its effects”.